Heavy Drinking & Alcohol Dependence: Remission & Recovery

1. Heavy Drinking & Alcohol Dependence: Remission & Recovery Mark L. Willenbring, MD Director, Division of Treatment & Recovery Research National Institute on Alcohol Abuse and Alcoholism National Institutes of Health Bethesda, MD, USA mlw@niaaa.nih.gov NIAAA

2. Definitions • Disease, illness or disorder: a condition characterized by failure of self-regulation of an organ or organ system, causing clinically significant impairment or distress, or an increased risk for development of same.

3. Definitions • Remission: disappearance of the signs and symptoms of a disease. • Partial remission: some but not all signs and symptoms are no longer present • Full remission: all signs and symptoms of a disease are no longer present

4. Definitions • Response: significant reduction in impairment or distress in the absence of full remission. • Non-response: no change or worsening of impairment or distress following treatment.

5. Definitions • Well-being is a measurable state characterized by dominance of positive over negative affect, effective coping, social support and productive activity.

6. Thesis • Recovery is a condition characterized by full remission and a state of well-being following an episode of illness • The primary roles of the health care system are risk reduction and treatment of disorder with the goal of achieving remission

7. Questions • Recovery from what? • Are remission and recovery different, and if so, how? • How do we measure remission and recovery? • What is treatment?

8. Questions • What are the goals of health care services? • What is the best way to achieve these goals? • What is the role of other institutions and activities in society vis a vis recovery?

9. Recovery from what? “Sorry, no water. We’re just a support group.”

10. Do we mean… • Alcoholism: a primary, progressive, incurable disease characterized by craving and loss of control over drinking, which, if not arrested, leads inevitably to physical, psychological, social and spiritual ruin and, ultimately, death?

11. Or do we mean… • Alcohol Dependence: a disorder characterized by impaired control over drinking, spending increasing amounts of time on it, use despite physical or psychological symptoms caused or exacerbated by it, tolerance and withdrawal (3/7 DSM-IV criteria within a one-year period)?

12. Or do we mean… • Chronic excessive alcohol use, which increases risk for acute problems, such as physically hazardous use and trauma, and for end-organ damage, primarily of the liver (fibrosis) and brain (dysregulation of the systems regulating pleasure, reward, motivation and incentive salience)?

13. Recovery from What? Diagnosis

14. Definitions • Standard drink: typical US drink containing about 14 grams of absolute alcohol • 12 oz. beer • 5 oz. wine (5 drinks per bottle) • 1.5 oz. shot of 80 proof spirits (11 drinks per pint

15. Definitions • Heavy drinking: exceeding NIAAA recommended maximum daily limits • Men: 5+ drinks in a day • Women: 4+ drinks in a day • Regular heavy drinking: monthly or greater • Alcohol use disorder: regular heavy drinking causing symptoms &/or dysfunction

16. Heterogeneity of Alcohol Use: Diagnosis DSM-IV Abuse/Dependence Mild (“At-risk”) Moderate (Harmful use) Severe (Dependence) Chronicdependence None 70% ~21% ~5% ~3% ~1% • Daily or neardaily heavydrinking • Current sequelae • Withdrawal • Chronic orrelapsing • Daily or neardaily heavydrinking • Current sequelae • Withdrawal • Exceedsdaily limits • Current sequelae • Exceedsdaily limits • No current sequelae Never exceedsdaily limits

17. Risk model of episodic heavy drinking and adverse outcomes Social dysfunction(“abuse”) Episodic heavy drinking Minimum 1x/month Usual 5-12x/month Trauma Acute illnesses

18. Risk model of regular heavy drinking and adverse outcomes Brain disease(addiction) Regular heavy drinking Minimum 1x/week Usual 4-7x/week Liver disease(fibrosis, cirrhosis) Other adverseoutcomes – Health & social

19. Alcohol Disorders in Heavy Drinkers Exceeds limitsweekly Dependence with Abuse Abuse Only Prevalence of disorder (%) Dependence without Abuse Days per year exceeds daily limits Johnson et al., The Lancet 361:1677-1685, 2003

20. Alcohol Disorders in Heavy Drinkers 35% = 57% Prevalence of disorder (%) 14% 8% Days per year exceeds daily limits Johnson et al., The Lancet 361:1677-1685, 2003

21. Alcohol Disorders in Heavy Drinkers 35% 43% of daily heavy drinkers do not meet criteria for any alcohol disorder = 57% Prevalence of disorder (%) 14% 8% Days per year exceeds daily limits Johnson et al., The Lancet 361:1677-1685, 2003

22. Alcohol Dependence SyndromeEdwards and Gross (1976). British J. of Addictions 1:1058-1061 • Narrowing of the drinking repertoire • Salience of drink-seeking behavior • Increased tolerance to alcohol • Repeated withdrawal symptoms • Relief or avoidance of withdrawal symptoms by further drinking • Subjective awareness of compulsion to drink • Reinstatement after abstinence

23. DSM-IV Diagnostic Criteria for Alcohol Use Disorders (AUD)

24. Quit/control Hazardous Use Tolerance Withdrawal Time spent Social/interpersonal Neglect roles Activities given up Legal problems An Alcohol Use Disorder Continuum Using Item Response Theory Saha TD, Chou SP, Grant BF (2006). Psychological Med., 36: 931-941

25. How Hazardous Drinking Relates to DSM-IV Alcohol Abuse and Alcohol Dependence – A Model* *Based on 30% endorsement of severity criteria by current drinkers (individuals who have consumed any alcohol in a month)

26. Dimensional Diagnosis of AUD? Alcohol Use Disorder Mild Moderate Severe Unremitting Risk Drinking • Daily or neardaily heavydrinking • Current sequelae • Withdrawal • Chronic orrelapsing • Exceedsdaily limits50+ times/yr • No current sequelae • Daily or neardaily heavydrinking • Current sequelae • Withdrawal • Exceedsdaily limits50+ times/yr • Current sequelae Exceedsdaily limits<50 times/yr

27. Natural History, Recovery and Relapse

28. U.S. Substance Abuse and Mental Health Services Administration 2003 National Survey on Drug Use and Health (NSDUH) Hazardous drinking peaks between 19-25 years of age

29. Prevalence of Alcohol Dependence Peaks Early Onset age 21 Past-Year DSM-IV Alcohol Dependence Age Grant, B.F. et al., Drug and Alcohol Dependence, 2004.

30. 1st Treatment in US is 8-10 years later 1st treatment age 31 Past-Year DSM-IV Alcohol Dependence Age Grant, B.F. et al., Drug and Alcohol Dependence, 2004.

31. Age in clinical trials is around 40 Average trial participant Past-Year DSM-IV Alcohol Dependence Age Grant, B.F. et al., Drug and Alcohol Dependence, 2004.

32. Heterogeneity of Course Chronic &severe Typical treatment case Early onset & recovery High Severity Chronic butmoderate Low 12 18 25 32 40 50 60 Age

33. Subtypes of alcohol dependence • Cluster 1: Young adult • Cluster 2: Functional • Cluster 3: Intermediate familial • Cluster 4: Young antisocial • Cluster 5: Chronic severe Moss H et al., Drug Alc Depen 2007

34. Subtypes of alcohol dependence (Moss et al., Drug Alc Depen 2007)

35. Subtypes of alcohol dependence 1/3 have mild self-limiting course in youth (Moss et al., Drug Alc Depen 2007)

36. Subtypes of alcohol dependence 40% have later-onset, moderate form with psychopathology (Moss et al., Drug Alc Depen 2007)

37. Subtypes of alcohol dependence 1/3 have early onset, severe chronic dependence (Moss et al., Drug Alc Depen 2007)

38. Severity predicts disability Hasin et al., Arch Gen Psychiatry 2007

39. Co-morbidity clusters in subgroup Hasin et al., Arch Gen Psychiatry 2007 *Odds ratios

40. Berkson’s Fallacy Berkson’s Fallacy (Berkson, 1946, 1955) occurs whenever the association between the independent variable and the dependent variable differs between the population from which the sample derives and the general population. Also known as the Clinician’s Illusion

41. Berkson’s Fallacy - Example • At autopsy, lower prevalence of cancer in people with TB  led to recommendation to infect cancer patients with TB • In fact, TB was more common in cancer cases that went to autopsy than those that did not! Pearl, 1929

42. Berkson’s Fallacy - Example • In a community sample of 2784, 257 people were hospitalized in a 6 month period • Large positive correlation between respiratory and locomotor diseases – connected? • They were independent – but people with both were much more likely to be hospitalized • 7-10% of people with one disorder hospitalized • 29% of people with both hospitalized Fleiss, 1981

43. Episodic nature of alcohol use disorders (AUD) • >70% have one episode only • Average episode lasts 4 years or less • Those who have >1 average 5 episodes • Episodes are of decreasing length Hasin et al., Arch Gen Psychiatry 2007

44. Abstainer 18.2% Dependent 25.0% Low risk drinker 17.7% Partialremission 27.3% Asx riskdrinker 11.8% Current Status of Adults with Prior to Past Year Dependence Full Remission 36% StillDependent 25% Partial Remission 39% Source: NIAAA

45. “Natural recovery” “Boy, I’m going to pay for this tomorrow at yoga class”

46. Most change occurs “naturally” • About one-quarter of people with AUD who recover ever receive any professional treatment or AA exposure • 13% have entered a treatment program • “All recovery is natural recovery” – Griffth Edwards 2005

47. Most change occurs “naturally” • Valliant (1995) found no temporal relationship between recovery and treatment • Pathways to recovery included new love relationship, substitute dependency, coercion, & religious/spiritual involvement • 70% of those achieving abstinence did so outside of treatment context

48. Natural Recovery • Treatment-seekers differ from “natural” recoverers • Less severe dependence; lower peak BAL • Less co-morbidity • Better social function and resources (social capital) Dawson 2005, Bischof et al. 2001, Fein & Landman 2005

49. Fein and Landman, 2005

50. Many people with SUDs remit spontaneously Dawson et al., 2004